Assessment of Flap Viability and Complication in Free Flap Reconstruction of Lower Third Leg and Foot Defects

Background:
Composite defects of the lower third leg and foot present significant
reconstructive challenges due to limited local tissue availability, poor
vascularity, and the frequent presence of exposed bone, tendon, or
implants. Free flap reconstruction has become the preferred method for
achieving durable coverage in this region yet flap viability and
complication patterns may vary depending on patient factors, defect
characteristics, flap type, and recipient vessels. Evidence from
Bangladesh is limited despite the increasing burden of lower limb trauma
and oncologic resections requiring microsurgical reconstruction.
Objective:
This study evaluated flap viability and early postoperative complications
following free flap reconstruction of distal lower limb defects in a
tertiary hospital setting.
Methods:
This prospective observational study was conducted in the Departments of
Orthopedics and Burn & Plastic Surgery at Sylhet M.A.G. Osmani Medical
College Hospital, Bangladesh, from July 2015 to June 2017. Eleven patients
with composite defects of the lower third leg or foot requiring free flap
coverage were consecutively enrolled. Data on patient demographics,
comorbidities, defect etiology and site, flap type, flap size, and recipient
vessels were collected prospectively. All free flaps were performed using
standard microsurgical techniques, with postoperative monitoring
following institutional protocols. Flap outcomes were categorized
according to the Srikant classification. Minor complications included
wound infection and partial graft loss, while major complications required
surgical intervention. Descriptive statistics were used for analysis.
Results:
All 11 free flaps demonstrated complete survival, resulting in a flap viability
rate of 100%. According to the Srikant classification, 72.7% of flaps
achieved Grade 1 outcomes, 18.2% achieved Grade 2 outcomes, and 9.1%
were Grade 3, reflecting partial non-critical losses. No cases of Grade 4 or
Grade 5 flap failure occurred. Minor complications were observed in 18.2%
of cases, and one major complication (9.1%) required secondary surgical
management. The anterolateral thigh (ALT) flap was most commonly used
(72.7%), while the anterior tibial artery served as the primary recipient
vessel (81.8%). Neither flap type nor vessel choice showed a clear
association with flap loss due to the overall high survival rate.
Conclusion:
Free flap reconstruction demonstrated excellent viability and low
complication rates in patients with composite defects of the lower third
leg and foot. The consistent success across flap types and recipient vessels
highlights the reliability of microsurgical reconstruction in this region.